Root Cause Analysis Flashcards
analytically identifies critical underlying reasons for the occurrence of an adverse event or close call (near miss)
Root Cause Analysis (RCA) of Medication Errors
what questions does root cause analysis answer?
- What happened?
- Why did it happen?
- What usually happens?
- What should have happened according to policies and procedures?
- What will prevent it from happening again?
- What actions need to be taken?
Using the medical record and interviewing the important participants in the patient’s care, describe in detail the event and activities leading up to it. When did the event occur? (Was it on a weekend or during off-hours?) What service areas were affected? Specify the injury or potential injury to the patient.
describe the event
The proximate cause explains why the event occurred. For example, assume that an adverse drug reaction (the event) occurred because the doctor wrote an order for a tenfold overdose of antibiotic (proximate cause) which the pharmacy dispensed (proximate cause) and the nurse administered (proximate cause). These proximate causes of the adverse event are deficiencies in the processes of care and hence, errors. It maybe helpful to construct a diagram of the event, showing the steps in the current process of care and steps where the process failed.
identify the proximate cause/s that led to the event.
Contributing factors permit errors to occur. For example, a nurse who forgot to administer a dose of medication may have been required to do a double shift. Fatigue and staff shortages would be contributing factors to this medication error.
identify the contributing factors (or latent errors) that led to the proximate cause.
Was staff adequately trained and skilled? Was staffing adequate? Was there appropriate supervision?
human resource issues
Was necessary information available, accurate and complete?
informational management issues
Did the physical environment contribute to the event? Are safeguards in place to minimize and address environmental risks?
environmental issues
Did the organizational culture impair self-care?
leadership and culture
Did the organizational culture impair self-care?
leadership and culture
This is the most important step of the analysis. The goal is to develop improvements that can be implemented and tested. How could one prevent this problem from happening again? Although education and training are important, improvements that rely on exhortation, education and reliance on memory are unreliable. The best action plans change the process of care itself.
create an action plan
To Err Is Human
The 1999 Institute of Medicine (IOM)
what are the two primary purposes of reporting programs the 1999 institute of medicine describes
- Hold providers accountable for performance and patient safety; and
- Provide information that leads to new knowledge and improved patient safety.
why do some hospitals resist the IOM’s call to accountability?
in fear that ADEs may be publicly disclosed
initial error reporting systems are important
- Improved management of individual patients
- Getting timely medical advice
- Providing a record of events
- Obtaining immediate legal counsel
what methods of reporting events must staff understand?
formal and informal wars of accepting information
what lines of communication will help to enhance trust and confidence?
informal lines of communication
reports may be submitted by…
e-mail, especially for external reporting systems
what should the organization that maintains the reporting system track
the effectiveness and usefulness of the various systems and make adjustments if necessary
event reporting forms with electronic formats are
provided by both internal and external reporting programs
what is the best approach whether or not it may cause serious harm
immediately report
advantages to immediate reporting
- An ADE that may not seem serious may, in fact, be serious
- The supervisor can ask questions while the event is fresh in the reporter’s mind
- An immediate oral report to a supervisor may be more beneficial than a hastily written report.
- Send final reports to risk management within 1 week of the event unless additional time is requested in the report
- Report to the external voluntary reporting system after all the information is gathered
what information should you primarily report?
just the facts
what should you include if there is a problem with labelling or packaging?
names of the products
include any ___________________________ as a result of the event
additional patient monitoring or testing performed or medications administered
include any explanatory information
- How the event happened
- What normally happens and how risk was managed before the event
- Why the event happened
- At-risk behaviors
- How to prevent similar events
what should you separate to better protect event analysis from discovery during a lawsuit
the causative and prevention portions from the factual
what should you never include in reports?
- personal / professional opinions
- conclusions
- criticisms
- accusations
- admissions
- patients’ names
what medication names should you use to prevent medication errors?
generic names
in what way would you prescribe to every customer to prevent medication errors?
tailor for individual patients
what should you practice learning and collecting?
medication histories
what medications should you should you take note of and be cautious of?
high-risk medications
be _______ with the medications being prescribed
very familiar
use __________ and remember the 5 Rs
memory aids
- patient
- drug
- route
- time
- dose
how should you communicate?
clearly
what habits should you develop?
checking habits
what should you encourage your patients to do?
be actively involved
what should you do to prevent medication errors?
report and learn from others
what should you do to drugs that could cause disastrous errors
lock up or sequester
what should you develop for drug storage
meticulous procedures
what should you reduce, design, and maintain?
reduce distractions, design a safe dispensing work environment, and maintain optimum workflow
what should you use to prevent mix ups between look alike and sound alike drug names?
labels and computer notes
what should you keep throughout the dispensing process?
original prescription order, label, and medication container together
what should you compare the contents of the medication container with?
information on the prescription
what should you enter into the computer and on the prescription label?
drug’s identification code )e.g national drug code [NDC])
what should you perform final checks on?
the prescription, prescription label, and manufacturer’s container
when possible, what should you use when performing final checks?
automation (e.g bar coding)
lastly, what should you provide?
patient counselling
lastly, what should you provide?
patient counselling
